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John W. Pawluk, DDS Qian Xie, DDS, MS, PhD Nihar Pillai, DDS Office: 6307294544 or 6308481898 Fax: 6307560281 www.endoillinois.com Patient:Referring Doctor:Name: ___Name: ___Date of Birth: ___Phone: ___Phone: ___Email: ___Email: ___Todays Date: ___Desired Treatment: Endodontic ConsultationDental ImplantRoot CanalCall Prior to TreatmentRetreatment___Endodontic Surgery Post Space DesiredNew Crown planned:YesHistory: PainFracture/CrackSwellingTraumaBite
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